In 2008, I sat as co-chair on the Canada Health Infoway Clinical Subcommittee (CSC) on standards. At that time, an important part of my agenda was to move forward messaging standards for EMR to EMR interoperability. In fact, it was due to the lack of commitment by Infoway in pursuing this goal that I finally resigned as co-chair and quit the committee. I was informed that EMR standards were #51 on the priority list of Canada Health Infoway's standard collaborative. See National Post article - Avoid the Boondoggle. Top 10 would have been worth fighting for, but #51 was too big a hill to climb at that time.

How this has come back to bite us all. Now that EMRs are well adopted by the majority of physicians across Canada, we have yet to achieve ubiquitous secure messaging capability between EMR systems. It is extremely difficult to reverse engineer this capability into EMR systems, not just to ensure the information is able to flow smoothly and dependably, but with semantic interoperability. In other words, the ability to ensure that information in one system, once transmitted, has the same meaningin the receiving system.

An announcement today in Technology for Doctors, QHR, Telus set to create national messaging standards is a welcome step in this direction. However, it is important to note that it has taken the EMR vendors themselves to move this agenda forwards, while at the same time inviting other EMR vendors to participate in the process. It is my hope that this truly represents the next critical step towards a more seamless and connected system for transfer of patient information between physicians and other care providers, particularly as shared care becomes more prevalent in private practice settings.

The top-down approach may have moved the acute care system and hospitals in the right direction, however they are still not without their difficulties. However, it boggles my mind that we could have missed the importance of EMR-to-EMR seamless interoperability. Particularly because the large majority of care in this country is provided by family physicians and specialists in private practice settings.

I anticipate a rising groundswell of physician dissatisfaction with the Status Quo. There is no reason in 2016 that we should still be functioning in practice or product specific data silos.

I hope we get it right this time. After an expenditure of multi-billions of dollars, we should be further along that we currently are.

So, how do we do it differently going forward? What are the key foundational requirements for success and what can we avoid repeating so that in 2025 we are not debating and arguing about the same issues?

A number of years ago I began to work in addictions, an area of practice that I now find extremely satisfying despite all of its inherent challenges. In comparison to family practice, with a practice roster of over 1,500 patients, I now look after less than 100 patients. Many of these have a high level of acuity as well as concurrent mental health issues and comorbid diseases such as HIV and Hepatitis C. While many patients struggle with their substance use issues on a daily basis, a significant number are stable and some have been in recovery for years. They are also very grateful for their recovery and continue to depend on their physicians, sponsors, support groups and counsellors to maintain their sobriety.

Patients with addiction issues have some unique challenges that make them very good candidates for remote care or telehealth. They may have to travel large distances to attend clinic appointments which is complicated by a need to depend on public transit. They frequently have financial issues as a result of their addictions, resulting in great difficulty if they need to purchase transit tickets. In addition, if working, they may be in remote locations, creating added difficulty in attending appointments consistently.

While telehealth is not appropriate for the majority of patients with addiction disorders, there is a specific patient population in which it is not only appropriate, but preferable to use telehealth services to provide care for these individuals. Telehealth is not a replacement for face-to-face care. It is an adjunctive tool that can be used very effectively to maintain continuity of care in situations in which it is difficult to see patients face-to-face.

In addiction treatment, developing a therapeutic alliance with a patient is a critical part of their recovery. Many of these individuals are victims of physical, mental or sexual abuse. They have been abandoned by friends and families and lack any structured support systems. It takes time to develop a therapeutic alliance upon which patients can depend, particularly when making difficult changes to behavior that are uncomfortable mentally as well as physically. Addiction patients are not good candidates for walk-in type care. They need this continuity in order to maintain their progress as well as their long-term sobriety.

Because mental health is so strongly associated with substance use, telehealth is an effective medium in order to support their care at a distance. Video conferencing allows the physician or counsellor to assess a patient in a way that cannot be done using the telephone. There are subtle body language cues that can be missed if one tries to depend purely on telephone support.

Our addiction medicine practice is fully EMR enabled. While this does not preclude other addiction practices from using telehealth to provide remote care to a subset of patients, it is certainly easier when one has computers in every room with videoconferencing capability.

One also needs a platform to provide teleconsultation services. I personally looked into a number of services, each of which has pros and cons. Polycom is an advanced teleconferencing system that is widely used in healthcare and within the provincial regional healthcare facilities, so using a Polycom system may make sense if you plan to provide teleconsultation services to patients in regional settings. After an extensive review I selected Medeo as my primary teleconhealth platform. Medeo provides a waiting room for patients, scheduling service, secure messaging and the ability to use desktops as well as mobile devices such as telephones or iPads. It is my opinion that Medeo is one of the leading telehealth platforms in Canada and one that could very effectively meet the needs of physicians who provide remote care to their patients.

Based upon my use of the platform, CanadianEMR will be promoting Medeo as a telehealth platform in 2015 for Canadian physicians.

In a letter to members sent out on March 12, 2014 by Doctors of BC (formally BCMA) President, Dr. William Cunningham confirmed that significant changes are about to take place with respect to the PITO funding program.

In summary:

The negotiated funds for the PITO program end on March 31, 2014. Attempts to negotiate further funds with government were unsuccessful and the PITO initiative is now considered complete and successful in reaching its objective of encouraging adoption of EMRs in community practices;

Approximately 5,000 physicians are now using EMRs in BC (90% of targeted physicians);

In order to assist physicians to reach a level of 'Meaningful Use' of their EMR systems, funding is being provided by the General Practice Services Committee and the Specialist Services Committee to support this optimization phase of EMR use for one additional year. Exact details of this funding are not yet available;

Ongoing monthly reimbursement of costs will no longer be paid beyond the conclusion of the contract - meaning that physicians will no longer receive funds to offset the cost of monthly vendor service fees (ranging from $200-$400 per month per physician).

Beyond the financial costs, Dr. Cunningham has recommended that physicians considering a transition from their ASP (remotely hosted) EMR systems to a local server version in order to reduce costs, think carefully about this change as only the secure ASP systems will be allowed to connect directly with provincial systems. This is particularly important in relation to new systems planned to start in the next 1-2 years.

The changes are dramatic, but not entirely unexpected. Physicians will begin feeling the bite of monthly EMR fees that were previously subsidized and will need to make adjustments to ensure that cash-flows are management optimally. Similar changes are expected in Alberta as the POSP program winds down at the conclusion of that province's provincial contract.

As more information becomes available on BC and Alberta, I will share through CanadianEMR.

It is now a couple of years since you have implemented your EMR. Your needs have evolved as you've become more proficient using the technology in your practice. In addition, your lease is up for renewal and you have important decisions to make. Do you renew your lease or move to a new practice location? Either may involve a refresh of the physical space with or without the financial support of your landlord. There are pros and cons either way, however staying in the same location and simply using the space more effectively reduces the needs for many of the administrative issues you may face. A major concern is disruption. How quickly can your office be refreshed? Is this turnkey or does the process continue piecemeal for days or weeks?

I had an opportunity recently to discuss these questions with a specialist in the office redesign market, Ruth Jankelowitz from the Janks Design Group.

AB: Ruth, as a design specialist, how do you respond to concerns about disruption to practice operations?

RJ: If you have a medical office that is tired or run down or are taking over an existing practice, scheduling and and tight timelines are critical. What we have done is develop a Five Day Makeover (FDM) that is best suited for renovations of existing offices/clinics. This renovation program incorporates weekend days resulting in only a 2 business day loss on the part of the clinic.

How does it work?

If planned well in advance, we recommend scheduling “On Call” duty for those days or maybe even a weekend away with the family;

We design and prepare all plans well ahead of implementation. We select all finishes, lighting, colours and ensure all ordering takes place well in advance to ensure every item is ready once we begin. In addition, detailed millwork plans are 100 % complete before raising a hammer;

Once everything is ready, the transformation begins...

A highly experienced construction team arrives on a late Thursday afternoon and removes all files and items to be stored/reused. The next step is to rip and strip (flooring, walls, furniture & lighting);

RJ: It is important that your design/implementation contractor understands your philosophy, demographics, tastes, target patient base and your budget. Our approach is to develop a conceptual design that best suits your needs and present it to you in 3D model so that you can virtually walk through the space and approve, before spending a penny on construction.

Once a conceptual design is in place, we prepare detailed permit & construction plans, handle permit process, issue detailed millwork and finishes plans for construction and assist through the entire construction process. Occasionally we also conduct tender processes and provide full project management services to some clients. Many of our clients, who are busy providing care to patients, want the project to be completely 'Turn Key' without any hassle or stress, so we manage the constraction as a project project.

AB: How can you be contacted if someone is interested in assistance or a quotation?

The latest issue of Future Practice explores the changing world of eHealth, provides an overview of the current and potential future state of provincial EMR funding programs, and looks at how doctors are using Twitter. Dr. Steve Hawrylyshyn and Dr. Naheed Dosani discuss the need for eHealth competencies from the resident physician perspective. Edited by Pat Rich, Future Practice provides an insightful view of topics that are at the leading edge of traditional clinical practice.

EMRs are complex software applications. The basic capabilities, such as clinical documentation, writing a prescription, and viewing lab results, are generally easy to use — but what about the more sophisticated functions? Think about your formal EMR training: was it limited to 1–2 days at the time of EMR implemention or have you subsequently received additional training? For the majority of EMR users, the likelihood is that the former is true. What this means is that there are many features you may be blissfully unaware of in your EMR. Some of these may be shortcuts or new ways of performing certain tasks that could save you and your staff hours per week. Each hour saved means $$ in your pocket.

Some of the ways that physicians and their practice teams keep up with the advances in their EMR are through annual user conferences or by setting up a local user group where one of the members of the team presents to the others on a certain functionality and essentially becomes the teacher for that particular capability. Alternately, each practice is recommended to have a super-user. This is someone who has received additional training to use the EMR and is able to answer questions and troubleshoot without the need to contact technical support. The super-user can be a physician, nurse, or administrative staff member — essentially anyone who has an interest and can take on and maintain this responsibility. Over time, by having additional expertise onsite in your practice, the benefits will be significant — not only financially, but also in terms of reduced stress when unexpected problems occur.

Vendors are continually enhancing their products. As provinces evolve beyond provincial certifications for EMRs (other than the ability for systems to share information more effectively), this process will accelerate. The reason for this is simple. With EMRs becoming ubiquitous in medical practices, and as the technology matures, the competition for new clients and to retain existing clients will intensify. The best products will begin to differentiate themselves through enhancements to usability, design, and functionality. In the not-too-distant future, all products will be able to do all basic functions, but the more advanced functions will frequently be the key differentiators. How will you keep up if you do not receive training on an ongoing basis? Another important reason to update your in-office training is staff turnover. Physicians join and leave practices, staff come and go, and frequently these users are not effectively trained to use the EMR beyond the basic functions. Often the trainer is someone who learned from someone else within the practice, resulting in the duplication of any poor processes that were passed on to that individual.

There is no getting away from the fact that ongoing training has a cost. At the same time, why would you invest all of your time, energy, and money into a tool that you use every day of practice and yet only use a small part of the functionality? Or have developed time-intensive workarounds for tasks for which there may be a simple solution?

Your EMR is a tool that needs to be effectively used. In order to do so, it is to your benefit to keep up to date with new features and functions beyond the quarterly update bulletin that your vendor sends out. Do yourself and your practice a favour: contact your vendor and arrange a training session. This is an investment that will pay for itself multiple times over, both in terms of time savings and costs.

Converting paper charts during EMR implementation
is generally seen as one of the greatest barriers to switching over a
practice. Chart conversion is a time-consuming and
resource-intensive task; however, there are several things your practice can do
to help shorten and reduce the pain of chart conversion. In order to maximize the benefits of your EMR, you will need to
pre-populate the record with important clinical and
demographic information. The following simple steps will improve your
successful transition from paper charts to an EMR.

Develop a plan that both indentifies the process you will use to
capture the information from your paper charts and establishes realistic
timeframes within which to complete the process. Consider the data that is most frequently going to be clinically
relevant in the treatment of your patients. One of the most common
mistakes is to attempt to input the entire patient chart into a new
system. Not only is this expensive, but also it can end up corrupting the data in the new
system.

Data you will most frequently need include the following: allergies,
current problems, current medications (episodic and long-term meds),
past medical and surgical history, important diagnostic results (e.g.
lab results, pathology, or most recent EKG), consult letters, immunizations, screening
test dates/results, and advance directives.

Here are some tips and best practices for chart conversion:

Review and update your paper charts prior to implementing your EMR.
Irrespective of which EMR you choose, you will need to get your charts
prepared for data input. Organizing the updated clinical data using a
standardized face sheet will streamline your data entry process when you
populate your EMR.

If you have more than one physician in your practice, it is important to agree upon a single standard paper template to collect this
information. This will allow you and your staff to pre-populate summary information and makes
the data you may want to transfer to your EMR more readily accessible
and faster to input into your EMR. It also gets you and your practice used
to documenting your patient visits in a structured manner that will
likely be similar to most EMR systems.

Identify patients who are seen regularly in your practice with
chronic medical conditions or complex care problems. Getting these paper
charts organized and entered into your EMR will allow you to focus on
the clinical encounter when you see that patient. It is much easier to
pre-enter all the complex patient data, which will allow you or your
staff to enter less complex patients on the day they are seen or during
the clinical encounter.

When choosing how to enter the data, remember that discrete
information such as immunizations or labs, if entered as a .pdf or TIFF
file will not populate any of the data fields in your EMR. As a result,
any alerts in your system will not be
reflected in this data.

If you choose to scan all of your old patient records, you will then
be able to move any remaining paper charts off-site and will be able to
reclaim space used for chart storage and utilize that space for other
purposes such as additional examination rooms. If scanned into a
compatible format (e.g. PDF), a copy of each scanned patient record can
be attached in your EMR allowing for quick review of the paper medical
chart if needed.

Establish a clear goal to keep everyone in the practice
motivated. One of the most effective strategies is the “three time rule”
where the physician is allowed to use the patient’s paper chart only
three times (three visits) before the paper chart is retired. After that
point, the chart is still accessible, but — as a deterrent — some
practices charge each physician a small fee per chart.

Have you converted from paper charts to an EMR? Share your experiences by clicking on the “Comments” link below.

For the last few years, as we all head back to work after a (hopefully) relaxing summer, I have shared some thoughts and insights on the health technology market and where I see it heading. Here are five insights and predictions for 2013/2014:

Big Data becomes last year’s buzzword. It seems as if every event, conference, and publication has had a chapter or section devoted to Big Data. However as reality has set in, big data has also meant “big challenges”. Making sense of terabytes of data requires not just incredible processing power, but also good quality comprehensive substrates to analyze. While an organization like Kaiser Permanente may be able to analyze big data collected through a closed system that extends from primary care to intensive care, the same is not true in Canada where large chunks of healthcare information sit in standalone databases, making it difficult to use predictive analytics to provide useful real-time clinical insights.

eReferral and data interoperability become the new buzzwords driven by a growing army of EMR-enabled physicians. With many provinces nearing or surpassing a critical mass of users of EMRs, physicians and their practice teams are becoming more sophisticated. Gone are the days where it was sufficient to optimize the EMR in one’s clinical practice. The demand will shift to data sharing and true interoperability between providers and systems. Get ready for a wide range of requirements driven by clinical users who are more focused on care than technology.

Mobile technology starts to become really useful. Consumers are already using mobile apps and devices such as fitness trackers to manage their health and demonstrate success. This is more than a fad and the advent of wearable technology will result in literally thousands of new applications and devices that will have a significant impact on patients and encourage physicians to integrate them more effectively into patient care.

Telehealth becomes more commonplace facilitated by reimbursement programs that recognize the value of treating patients at a distance. Many physicians and organizations are now using maturing telehealth technologies to consult with patients and facilitate follow up visits without bringing the patient into the office for a face-to-face encounter. Companies to watch include Vancouver-based startup Medeo.

The message becomes the foundational building block of a maturing EMR market and healthcare system. Ten years ago, provinces focused on developing functional specifications and certifications for EMR systems. As the provincial programs evolve further, with a growing need for data interoperability between EMRs and other clinical systems, the focus will shift towards standardized messaging so that information can easily be shared and reproduced. Functional specifications will become less relevant and less important.

Do you agree or disagree? Share your thoughts by clicking on the “Comments” link below.

Is the quality of documentation better using EMRs or paper? Readers of this blog will be very interested in receiving feedback from physicians and office staff who have been using an EMR for their clinical documentation for a couple of years or more. If you have never used a paper chart, it may be difficult to make the comparison, for example new graduates who have been trained in facilities and practices that only use electronic record systems. However the majority of physicians in clinical practice today will still remember the paper record — some with a sense of nostalgia and others a sense of relief.

There is something elegant about a well-crafted clinical note that tells the story of the patient (whether it be electronic or on paper), particularly if that note can be crafted into a patient summary or referral/consultation letter that accurately describes the patient's clinical problem in a manner that is helpful to the treating physician. Earlier this year, while working in Singapore on a medication project, a colleague lamented to me about the state of clinical documentation. He described a time pre-EMR when physicians would take the utmost care to think about the clinical status of their patients and would painstakingly document their findings including a summary and plan and would integrate lab and diagnostic information into the narrative. In contrast, he felt that the prevalence of electronic clinical documentation systems had made physicians lazy — it was easier to generate a report by selecting checkboxes and date ranges for clinical encounters than ensuring the summary was accurate, logical and clear. It’s all about the building blocks. If you are not inputting quality information, it is difficult to get decent information out of the chart.

Back to the original question. Is the quality of documentation better in one medium vs. the other? From a legibility perspective, EMR wins hands down as typed trumps handwritten notes in the vast majority of cases. In fact, as we become more comfortable using technology, I believe that the quality of penmanship further deteriorates. Narrative vs. structured data recorded in the EMR? While I fully understand the need for discrete data in the EMR in order to graph, search, and analyze, I much prefer reading a narrative note, particularly if it is detailed. Trying to reconstruct a clinical encounter from a series of bullet points may work for common conditions such as UTIs or Hypertension monitoring, but it is extremely difficult for mental health problems or multi-system disease. Some of the patient summaries and printouts generated by EMRs are dreadful both in terms of format and content. Sifting through reams of discrete lab results, each on a separate line, or encounters that do not make any logical sense is very frustrating.

An article on AmericanEHR.com titled, “Are You Proud of Your Documentation Using an EHR?” drew some insightful feedback. Personally, I do not believe that technology is the problem. It is more related to how that technology is being used, whether the templates and clinical encounters have been optimized for data entry, the ease of use of the EMR regarding data entry, and whether the system can generate a record that is as good, if not better, than a well-written narrative note.

What is your experience? Are you satisfied with the documentation in your EMR? If not, what would you change to make it better?